Georgia Medicaid DSH Audit Training September 9 th & 14 th , 2010

1. Georgia MedicaidDSH Audit TrainingSeptember 9th & 14th, 2010 Jim Erickson, Member Myers and Stauffer LC

2. Training Overview • Update on ’05, ’06 & ‘07 DSH Audits • Review of DSH Data Requirements for DSH Audit and Payment Processes • Review of the Medicaid DSH Survey Tool • DSH Payment Calculation • Questions and Answer Session

3. Update on DSH Audits • Fieldwork and Desk Reviews are complete, currently going through supervisory review process • Final reports for all three years are due to CMS by 12/31/10

4. Questions/Comments?

5. DSH Data Requirements Audit & Payment • 2005 & 2006 DSH Audit • Collected data from cost reports that cover: • 7/1/04 – 6/30/05 (SFY ‘05) • 7/1/05 – 6/30/06 (SFY ‘06) • 2007 DSH Audit • Collect data from cost reports that cover: • 7/1/06 – 6/30/07 (SFY ‘07) • 2010 Payment / 2008 DSH Audit • Cost reports ending in 2008 • 2011 Payment (Current Survey) • Cost reports ending in 2009

6. DSH Data Requirements Audit & Payment • Example Provider with 12/31 Fiscal Year: Cost Report Periods 1/1/09 – 12/31/09 1/1/08 – 12/31/08 1/1/06 – 12/31/06 1/1/07- 12/31/07 1/1/04 – 12/31/04 1/1/05 – 12/31/05 SFY ‘05 DSH Audit SFY ‘06 DSH Audit SFY ‘07 DSH Audit SFY ‘08 DSH Audit SFY ‘09 DSH Audit SFY ‘11 Payment

7. Questions/Comments?

8. Medicaid DSH Survey General Instruction and Identification of Cost Report Years • Select your hospital from the drop-down menu • Verify provider number is correct • DSH year begin and end dates will populate • Verify Items 4 & 5 (Owner/Operator Type, and DSH Pool) are Correct (As of the Completion of the Survey) • (Center Box (“Correct?”) is a drop-down “Yes/”No” Response, if response is “No” provide correct information in the last box.

9. Medicaid DSH Survey General Instruction and Identification of Cost Report Years • Answer survey questions 6, 7 and 8 to determine if hospital is eligible to receive DSH payments (OB Questions) • Supporting documentation for all DSH survey responses must be maintained by your hospital (for a minimum of 5 years)

10. Medicaid DSH Survey Section A – Cash Subsidies and Charity Care Charges • The state must report your actual MIUR and LIUR for the DSH year - data is needed to calculate the LIUR • Provide the amounts for each cost report year needed to cover the DSH year • If cash subsidies are specified for I/P or O/P services, record them as such, otherwise record entire amount as unspecified

11. Medicaid DSH Survey Section B – Out of State Medicaid Provider Numbers • List your Medicaid provider names and numbers for states other than Georgia • If more lines are needed than provided on the form, attach a complete list to your survey

12. Medicaid DSH Survey Section C – Net hospital revenue from patient services • Information is needed to determine your actual LIUR for the DSH year. A separate schedule must be used for each cost report year covering a portion of the DSH year. • Data elements used in calculation are: • Inpatient hospital charges • Net hospital revenue Note: The form provides space to allocate contractual allowances among service centers. If such an allocation is not reasonable, record a single amount for hospital services and a single amount for non-hospital (i.e., hospital-based skilled nursing facility, home health agency, etc.) services

13. Medicaid DSH Survey Section D – Calculation of Medicaid and Uninsured Costs (Using Cost Report Methods) • For each cost report covering a portion of the DSH year, the hospital should record the routine per diem costs and ancillary cost-to-charge ratios for each cost center. Use cost report schedules D-1 and C for these values • Enter inpatient (routine) days, I/P and O/P ancillary charges. The form will calculate cost for: • In-State FFS Medicaid • In-State Managed Care • In-State FFS Cross-Over • In-State Managed Care Cross-Over • Payment data should agree to HS&R (or paid claims report from MMIS) reports from Medicaid and/or managed care agencies

14. Medicaid DSH Survey Section D – Calculation of Medicaid and Uninsured Costs (Using Cost Report Methods) • For uninsured services, patient days (by routine cost center) and ancillary charges by cost center are needed • Survey form Exhibit A shows the data elements that need to be collected and provided to Myers and Stauffer. This data will allow us to cost your uninsured services using cost report mechanics • Uninsured services need to be identified for each cost reporting period covering a portion of the DSH year.

15. Medicaid DSH Survey Section D – Calculation of Medicaid and Uninsured Costs (Using Cost Report Methods) • Payment received for uninsured services need to be reported on a cash basis • For example, a cash payment received during the ’09 DSH year (7-1-08 thru 6-30-09) that relates to a service provided in calendar 2004 must be used to reduce uninsured cost for the ’09 DSH year • Survey form Exhibit B has been designed to assist hospitals collect and report uninsured payments received data • DSH hospitals should make a reasonable effort to identify insurance status when care was provided for all patient payments received during the DSH year. If service dates are so outdated that insurance status cannot be identified, report these cash collections on Exhibit B-1. Payment will be allocated between insured and uninsured using your collection stat during the time period when insurance status could be identified

16. Medicaid DSH Survey Section D – Calculation of Medicaid and Uninsured Costs (Using Cost Report Methods) • Uninsured Services: Uninsured patients are individuals with no source of third party health care coverage (insurance). If the patient had health insurance, even if the third party insurer did not pay, those services are insured and cannot be reported as uninsured on the survey

17. Medicaid DSH Survey Section E – Out of State Medicaid Services • Medicaid days, ancillary charges and payments received must be reported on this section of the survey. The cost and payments for another state’s Medicaid services are included in your hospital’s uncompensated care costs • The data needed should be reported in the same format as data on Section D. Days, charges and payments received must agree to the other state’s HS&R (or similar) claim payment summary • If your hospital provided services to several other states, please consolidate your data and provide detailed support for your survey responses

18. Medicaid DSH Survey Section F & G – Transplant Hospital Organ Acquisition Costs • These schedules should be used to calculate organ acquisition cost for Medicaid (in-state and out-of-state) and uninsured • Report data for each cost report year needed to cover the DSH year • Summary claims data (HS&R) or similar documents and provider records (organ counts) must be provided to support the charges and usable organ counts reported on the survey

19. Medicaid DSH Survey Section H – Section 1011 and Out of State DSH Payments • Section 1011 provides reimbursement for emergency health services furnished to undocumented aliens. Because a portion of the payments are made for cost recognized for DSH, a portion of these payments must be recognized on behalf of uninsured hospital services • You must report your Section 1011 payments included in payment on Exhibit B (posted at the patient level), received but not included in Exhibit B, and separate the 1011 payments between hospital services and non-hospital services (non-hospital services include physician services) • If your facility received DSH payments from another state (non-Georgia DSH payments), these payments must be reported on this section of the survey

20. Medicaid DSH Survey Certification • Answer the question addressing if your hospital was allowed to retain 100 percent of the DSH payments it received. Providing IGT/CPE funding is not the basis for a no answer • The hospital’s CEO or CFO must certify as to the accuracy and completeness of your survey responses • Provide contact information for person(s) responsible for completing survey

21. Medicaid DSH Survey • Submission Checklist • A Checklist Tab is Provided in the Survey Document, please include all items on the checklist with your submission. • Checklist Includes a copy of your cost report (.ECR) file. Please include the cost report utilized in completing the survey.

22. Medicaid DSH Survey • Due Date – October 15, 2010 • Hospitals not submitting by the due date will not receive an interim DSH payment.

23. Medicaid DSH Survey • Items Noted from 2010 Survey Reviews: • HS&R Reports – Use the odd number reports (Summary Type I, III, V, and VII) • Ambulance Charges and Payments – should be excluded from the data for uninsured and other payer types as it is not defined as an Inpatient or Outpatient hospital service within the Medicaid state plan and therefore under federal regulations can not be included in the DSH limit calculation.

24. DSH Payment Calculation • Eligibility • Must have Medicaid I/P Utilization Rate of at Least 1%, AND • Meet the OB Requirement • 2 OB’s who have agreed to provide OB services to Medicaid recipients • Meet one of the exceptions: • Does not apply to hospitals serving predominately individuals under 18 • Does not apply to hospitals that did not perform non-emergency OB as of 12/22/87

25. DSH Payment Calculation • DSH Limit • Uncompensated care costs of the following In-State and Out-of-State Services: • Medicaid FFS • Medicaid Managed Care • Cross-Over Claims • Uninsured • In-State Long fall/(Shortfall) calculated in Section D of the Survey • Out-of-State Long fall/(Shortfall) calculated in Section E of the Survey

26. DSH Payment Calculation • Adjustments to DSH Limit for Allocation Purposes • IGT portion of any UPL payment received on behalf of the hospital is added back • Hospitals receiving rate adjustment payments related to Med Ed, Neonatal Services, or services provided under contract with Georgia Department of Human Resources will be added back to allocation factor.

27. DSH Payment Calculation • Allocation of Funds • Two Pools of Eligible Hospitals • Small Rural (Under 100 Beds, not in MSA or is in a county of less than 35,000 excluding Military base personnel and their dependents. ($53,735,261 in 2008 changes relative to change in Federal Allotment) • Non-Small Rural – does not meet the definition of small rural. ($347,439,065 in 2008 changes relative to change in Federal Allotment).

28. DSH Payment Calculation • Allocation of Funds • Step 1 – Adjusted DSH Limit divided by Total Hospital Cost. • Step 2 – Adjusted DSH Limit multiplied by fraction from Step 1 (private hospitals then also multiplied by FMAP) • Step 3 – Result of Step 2 divided by total of Step 2 results for all hospitals in respective pool • Step 4 – Step 3 results times dollars available in that pool.

29. DSH Payment Calculation • Allocation of Funds • Hospitals can not exceed their calculated DSH Limit (before adjustments for UPL/IGT, and Rate Adjustments) • If a hospital goes over their DSH limit it is redistributed to other hospitals in their pool who have not gone over.

30. DSH Payment Calculation • Additional Allocation Parameters • Maximum DSH Allocation to an individual hospital is 75% of their adjusted DSH Limit • Hospitals not Eligible for DSH payments prior to 12/1/07 their maximum allocation facto in Step 2 above is 25% of the calculated amount. • Small Rural Hospitals – Blended at 50% of 2007 DSH calculation and 50% of current. • Non-Small Rural Hospitals – Blended at 25% of 2007 DSH calculation and 75% of current.

31. Questions/Comments?

32. Other Information: Please use the DSH Survey Submission Checklist Send survey and other data to: Myers and Stauffer LC Attn: Georgia DSH Survey 11440 Tomahawk Creek Parkway Leawood, Kansas 66211 Questions: Phone: (800) 374-6858 e-mail: gadsh@mslc.com